Republika ng Pilipinas

LALAWIGAN NG RIZAL

Road A Phase IV COGEO Village, Barangay Bagong Nayon, Antipolo City 1870 Rizal, Philippines
 barangay_bagongnayon@yahoo.com   647-0942   942-0358   bagongnayon.antipolo@gmail.com
www.facebook.com/BagongNayonOfficialPage   www.antipolo.ph

KP PORMULARYO BLG. 17

BARANGAY CASE NO. _______________

____________________________
COMPLAINANT/S
____________________________
____________________________
(Address)

AGAINST: FOR:

____________________________ ____________________________________
RESPONDENT/S
____________________________ ____________________________________
Barangay Bagong Nayon,Antipolo City
(Address)

REPUDIATION
I/WE hereby repudiate the settlement/agreement for arbitration on the ground that my/our consent
was vitiated by: (Check out whichever is applicable)
[] Fraud. (State details) ______________________________________________________
_______________________________________________________________________
_______________________________________________________________________
[] Violence. (State details)____________________________________________________
_______________________________________________________________________
_______________________________________________________________________
[] Intimidation. (State details) _________________________________________________
_______________________________________________________________________
_______________________________________________________________________

This ________ day of _____________, 20____.

Complainant/s Respondent/s
____________________________ ____________________________
____________________________ ____________________________

SUBSCRIBED AND SWORN TO before me this ________ day of __________, 20____ at

_____________.

_____________________________________
Punong Barangay/Pangkat Chairman/Member

Received and filed * this ______ day of ______________, 20_____.

____________________
Punong Barangay
* Failure to repudiate the settlement or the arbitration agreement within the time limits respectively set (ten [10]
days from the date of settlement and five[5] days from the date of arbitration agreement) shall be deemed a waiver
of the right to challenge on said grounds.
Barangay Bagong Nayon: Kabalikat sa Kaunlaran at Pagbabago ng Lungsod ng Antipolo.